April 12, 2005

HEALTH PLANS/POLICY: It will stagger you to find out that health care competition may not result in better quality!

Now I want you all to sit down comfortably and drink a glass of water before you read this article. Says here (in a story cribbed from the academic journal Medical Care) that Health care competition may not result in better quality. The study found that HMOs in places where there was less competition between HMOs did better on HEDIS scores. Oddly those where there was more enrollment in HMOs also did better on HEDIS scores (though not as well on consumer satisfaction). All suggesting that a single monopoly HMO probably does best of all on quality. Um, does this sounds like anywhere we know? Well now you've all recovered from the shock, let's review what little that we know on the subject.

a) Competition amongst health plans and HMOs is not about the competition to produce the best quality care. It's about the competition to insure as many as possible of the people least likely to need it. Harsh but fair words.b) In general health plans have little ability to control what medical providers do, and providers are the ones who do the things that make up HEDIS scores. Consumer satisfaction with health plans has to do with customer service reps, not health care quality which the average consumer wouldn't recognize even if it showed up as their prom date.c) The more health plans there are in an area the less each plan's ability to get providers to do anything, as they'll be responsible for a very small part of the provider's businessd) As Porter, Enthoven and a host of other bright people have pointed out, competition such as it exists in the US system is in the wrong place (see point a).And e) no one in the real world, where people and employers vote with their money, cares about HEDIS or has even heard of it.

I hope no one working hard in a health plan feels too offended. Sorry for feeling bloody minded tonight, but my next chore is to do my taxes! I'm sure you understand!

Comments

I work at a health plan and I am not offended. It is true. Competition in an area is mostly driven by market share. Which in turn is mostly driven by price, not HEDIS (most people have never heard of it, or care for it).

Part of the reason for this because of the backlash against managed care plans which caused most plans to simply back away from the mission of "directing treatment". HEDIS is worthless to a healthplan because patients and providers do not welcome the intrusion.

If patients were really concerned about quality they switch doctors or hire an attorney. The last thing they do is complain that their HMO is not providing access to their immunization shots.

Kaiser PR people, however continue to cite NCQA in articles and commercials for their current brand campaign because Kaiser has made a big investment in their NCQA ratings. So at this point it seems that Kaiser's big marketing research effort didn't register with the Powers That Be, who've probably all planted personal career stakes in Quality measurement and reporting.

This is one of those situations where professional momentum diverged from the actual interests of the customer. It may be worth reserving seats and buying popcorn for the spectacular Moment of Reckoning when Kaiser members finally catch on to where their membership fees are going and they realize what percentage is siphoned off by pure silliness. Yes, you the patient are paying for those NCQA consultants, and those are the guys who get fitted out with next generation laptop, pda, blackberry, cellphone, and a lunch account. And then you pay for all those HEDIS systems the consultants use and recommend. If HEDIS has no relationship to quality from a patient's perspective, then this is all a colossal waste of money.

Posted by: gadfly | Apr 13, 2005 5:15:01 PM

My experience is in mental health, and the MBHO I worked for also spent a lot of money on NCQA accreditation and put effort into raising our HEDIS numbers.

I can't speak for the medical side of things, but in mental health, the HEDIS measures actually do correlate to quality treatment. The main measures were outpatient followup within 30 days of inpatient discharge and seeing a clinician within 2 weeks of first request. Followup appointments are crucial in reducing recidivism, and it's important for prospective patients to see a clinician while they're still in the window of time where they're receptive to care.

My company performed plenty of initiatives including enhanced discharge planning during which the importance of follow-ups was emphasized, and also calling members post-discharge to remind them to make their follow-up appointment. This had real impact on recidivism rates.

Just because nobody is paying attention to HEDIS measures doesn't mean that they're not an important measure of the quality of care patients are receiving.

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